Grow Great

Driving a national commitment to a stunting-free generation by 2030

About this image: This is Dean Jates and his son Lesedi walking around the Cape Town city centre in 2016. Dean is a doting dad who is passionate about fatherhood and about inspiring other fathers to share this passion. Read Dean’s story here.

About this image: This is Dean Jates and his son Lesedi walking around the Cape Town city centre in 2016. Dean is a doting dad who is passionate about fatherhood and about inspiring other fathers to share this passion. Read Dean’s story here.

What

Stunting, which results from poor nutrition and disease, is a condition that prevents children from reaching their full growth potential. Typically defined as being short for one’s age – the impact of stunting goes far beyond height, however. Stunting is also associated with lifelong cognitive defects, educational and employment challenges, increased risk of chronic diseases in adulthood and ongoing cycles of intergenerational poverty[1]Victoria C, Adair L, Fall C. 2017. Maternal and child undernutrition: consequences for adult health and human capital. Lancet 2008;371(9606):340-357.. Stunted children are therefore unjustly deprived – not only in terms of reaching their full growth potential – but more crucially, of achieving their full cognitive potential, too.

The prevalence of stunting is worryingly high among South African children, with prevalence rates estimated at 27% in children under five[2]Statistics South Africa. South Africa Demographic and Health Survey 2016: Key Indicator Report. – far higher than many of South Africa’s developing country counterparts[3]Department of Health, Department of Monitoring & Evaluation, Department of Social Development. 2014. Final Evaluation Report: Short Diagnostic/Implementation Evaluation of Nutrition Interventions for Children from Conception to Age 5..

No child should be deprived of a healthy future from preventable causes.Grow Great aims to drive a national commitment to a stunting free generation by 2030.

About this image: This is Sisanda Ganga photographed at the Philani Clinic in Khayelitsha when she came for a regular check-up with her mother in July 2018.

About this image: This is Sisanda Ganga photographed at the Philani Clinic in Khayelitsha when she came for a regular check-up with her mother in July 2018.

Why

Research shows that stunting in early life – particularly in the critical window of the first 1 000 days of life from conception until the age of two – places children at a severe disadvantage when it comes to their learning ability for the rest of their lives, resulting in them starting school later; performing more poorly on tests for reading and intelligence; achieving lower grades and being less likely to complete school than their non-stunted counterparts. When these children are followed into adulthood, they are found to live in poorer households; attain lower occupational status and earn less; they are also found to suffer higher rates of metabolic disease, diabetes and obesity (see the infographic provided below for details on these statistics as well as full references). The economic costs of childhood undernutrition, in terms of lost productivity and economic growth, are therefore significant and of utmost national concern.

Stunting is in many ways at the heart of the gross inequality in our country – that even before babies are born, they are already on a trajectory that leads to poor educational attainment, chronic ill health and poverty.

But, as recent data from the World Bank suggests, investing in childhood nutrition is one of the most cost-effective development actions we can make: globally, every $1 invested in averting stunting achieves an $11 economic return[4]Shekar M, Kakietek J, Eberwein J, Walters D. 2017. An Investment Framework for Nutrition: Reaching the Global Targets for Stunting, Aneamia, Breastfeeding, and Wasting. Directions in Development.. Nationally, a stunting-free generation would increase our GDP by at least 2% or ± R80-billion, and enable one million more children to thrive each year.

The facts about nutritional stunting in South Africa

How

Stunting is not just about a lack of food. It can be the outcome of a number of factors, such as poor maternal health (pre- and post-pregnancy); poor breastfeeding and complementary feeding practices; poor hygiene and sanitation; gastrointestinal infections and/or worms; as well as a lack of dietary diversity and the purchasing power of low-income households[5]Said-mohamed R, Micklesfield L, Pettifor J, Norris S. Has the prevalence of stunting in South African children changed in 40 years? Asystematic review. BMC Public Health 2015;15(1):1-10. . Grow Great has therefore adopted a multi-pronged approach to tackle the key drivers of stunting in South Africa:

Provide universal access to antenatal and postnatal classes that support and celebrate mothers in the critical first 1 000 days

Early intervention during pregnancy can result in significant gains on stunting[6]Danaei G, Andrews K, Sudfeld C, Fink G, McCoy C, Peet E, et al. Risk factors for Childhood stunting in 137 Developing Counries: A comparative risk assessment analysis at global, regional and country level. Plos Medicine 2016;13(11):1-18. because many mothers and primary caregivers are unsupported to exclusively breastfeed and to provide the nutritious food and healthy environments that young children need to ‘grow great’. While clinical nutrition interventions are being delivered through health facilities, communities of support for pregnant women and young children that provide space for peer learning, encouragement and celebration are not readily available to the majority of South Africa’s moms; where they do exist, are particularly poorly implemented[7]Department of Health, Department of Monitoring & Evaluation, Department of Social Development. 2014. Final Evaluation Report: Short Diagnostic/Implementation Evaluation of Nutrition Interventions for Children from Conception to Age 5..

Using a social franchising model, Grow Great will facilitate access to high-quality and affordable antenatal and postnatal classes that support and empower pregnant mothers and babies during the critical first 1 000 days. Using a carefully crafted curriculum that speaks to the various drivers of stunting in a way that excites and inspires mothers, these antenatal and postnatal classes will create communities of companionship, belonging and acceptance where mothers have an opportunity to come together, nurture themselves and the little body growing inside of them and forge the future they want for themselves and their children.

At present, access to high quality support in pregnancy and during the post-partum period is a luxury enjoyed largely by South Africa’s wealthiest communities. Grow Great hopes to have these classes available at scale by 2024, prioritising the 300 000 households most at risk of having children with stunting.

About this image: This is Mosizakhe Bottomone and his baby photographed at the Philani Clinic in Khayelitsha. Mosizakhe was taking primary responsibility for his baby because his wife was sick at the time that the picture was taken in July 2018.

About this image: This is Mosizakhe Bottomone and his baby photographed at the Philani Clinic in Khayelitsha. Mosizakhe was taking primary responsibility for his baby because his wife was sick at the time that the picture was taken in July 2018.

2

Catalyse Community Healthcare Workers into ‘Champions for Children’

A healthy child typically only interacts with the health system for 20 of the first 1 000 days of life; engaging with the child and the primary caregiver in the home is therefore an important strategy to prevent stunting. In a number of developing countries that have managed to significantly reduce stunting rates in the country, Community Healthcare Workers (CHWs) played a central role in reduction strategies[8]World Health Organization. Essential Nutrition Actions: Improving Maternal, Newborn, Infant and Young Child Health and Nutrition. 2013..

Grow Great will therefore galvanise South Africa’s CHWs around a shared vision that seeks to promote and secure the wellbeing of South Africa’s children. A national CHW club has been created that recognises and affirm CHWs for the important work they do in the home and unites them under the same vision i.e. to be ‘Champions for Children’ in their communities. Community Healthcare Workers who join this opt-in club benefit from

A telephonic information line;

Opportunities for training on the first 1 000 days;

Recognition and rewards for being ‘Champions for Children’ in their communities; and

Access to a social network of other CHWs across the country.

The Grow Great campaign aims to sign up 10 000 CHWs to the ‘Champions for Children’ club by 2030.

About this image: This is a nurse at the Philani Clinic in Khayelitsha holding the two twins of a client in July 2018.

About this image: This is a nurse at the Philani Clinic in Khayelitsha holding the two twins of a client in July 2018.

3

Change the culture of early childhood-feeding practices through mass media communications

Almost all women are capable of breastfeeding, except a tiny few who suffer from medical conditions that make breastfeeding difficult[9]Rollins N, Bhandari N, Hajeebhoy N, Horton S, Lutter C, Martines J, et al. Why invest, and what it will take to improve breastfeeding practices? The Lancet 2016;387(10017):491-504.. Breastfeeding is protective against many childhood ailments, some of which, like diarrhoea, are direct drivers of stunting; it is also associated with a 2.6 point increase in the IQ of a child[10]Ibid.. Given these significant advantages, improving the very low breastfeeding rates in South Africa is a relatively cheap and sustainable way of addressing our high stunting rates.

The Tshwane Declaration expresses South Africa’s political will to ensure the promotion, protection and support of breastfeeding[11]Du Plessis L, Pereira C. Paediatric Food-Based Dietary Guidelines for South Africa:Commitment and capacity for the support of breastfeeding in South Africa. . S Afr J Clin Nutr. 2013;26(3):S120-S128.. However, complex barriers, such as community perceptions and beliefs; limited breastfeeding education; employers and employment spaces that do not enable breastfeeding; the perceived sophistication associated with formula feeding and the stigma associated with public breastfeeding, continue to curtail the extent of exclusive breastfeeding in South Africa.[12]Witten C. South Africa has made giant strides in breastfeeding. But it’s still taboo in public places<br />. The Conversation 2017:19 October 2017.,[13]Goosen C, McLachlan M, Schübl C. Factors Impeding Exclusive Breastfeeding in a Low-Income Area of the Western Cape Province of South Africa. Afr J Nurs Midwifery. 2014;16(1):13-31.

Evidence suggests that a well-crafted media campaign reinforced by breastfeeding support in the home and community can shift public perceptions of breastfeeding and improve breastfeeding rates[14]Rollins et.al.,[15]World Health Organization. Viet Nam breastfeeding campaign normalizes practice, improves rates. 2016; Available at: http://www.who.int/features/2016/Viet-Nambreastfeeding-campaign/en/. Accessed 10/19/2017, 2017.. Grow Great is therefore running a series of mass media breastfeeding campaigns that aim to normalise breastfeeding and increase its value in society. The campaign messaging will be reinforced during the antenatal and postnatal classes, and through the counselling and encouragement provided by Community Healthcare Workers to families in their homes.

The promotion of exclusive breastfeeding for the first six months will be followed by campaigns supporting and educating mothers to transition from breastfeeding to healthy weaning practices, specifically the foregrounding of eggs as a nutritious weaning food.

There is currently a lack of caregiver knowledge on what complementary foods to introduce and when. Most infants are introduced to cereal-based solids, typically before six months, which may be calorie-dense but micronutrient deficient. Growth faltering is particularly evident between six and 12 months when foods of low nutrient density begin to replace breast milk or formula milk, and rates of diarrhoeal illness caused by food contamination are at their highest. According to the Demographic Health Survey in 2016, only 23% of infants between six and 23 months receive a minimum acceptable diet[16]Hall K, Sambu W, berry L, Giese S, Almeleh C. 2017. South African Early Childhood review.. Eggs are an affordable weaning super-food that are easily accessible in most communities.

About this image: This is Asandiswa Mbaliand and one of her twins photographed at the Philani Clinic in Khayelitsha. Asandiswa explained to us how hard it is to look after two babies living in a shack with no stable source of income except for child support grants in July 2018.

About this image: This is Asandiswa Mbaliand and one of her twins photographed at the Philani Clinic in Khayelitsha. Asandiswa explained to us how hard it is to look after two babies living in a shack with no stable source of income except for child support grants in July 2018.

4

Drive national commitment to a stunting-free generation by 2030 through data-driven advocacy

Towards positioning stunting as a national imperative, Grow Great will create a ‘Zero-Stunting Scorecard’ or scoring index that will shine a spotlight on our progress addressing the issue. The score card will draw on community level primary data collected by Community Healthcare Workers with the aim of illustrating the situation in selected stunting hotspots in the country, while advocating for regular and detailed data collection on the nutritional status of South Africa’s children.

The scorecard will be used:

As an advocacy tool to spark a broader national discussion around stunting;

As a talking point for community imbizos;

To identify vulnerable communities; and

To inform policy and local program implementation.

The scorecard will combine the strength of top-down high-level advocacy towards systemic change, complemented with bottom-up data that points to intervention opportunities, thus charting a clear course for eradicating stunting in South Africa.

About this image: Nutrition worker, Nomzekeliso Pita measures a baby at the Philani Clinic in Khayelitsha in July 2018.

About this image: Nutrition worker, Nomzekeliso Pita measures a baby at the Philani Clinic in Khayelitsha in July 2018.

Progress

In 2018, Grow Great is piloting and developing its key initiatives.

By mid-year:

Pilot sites to test policy recommendations and research partners have been identified for stunting baseline surveys. A stakeholder engagement plan has been drawn up and consultations with some of the leading policy-makers have started.

The first cohort of Community Healthcare Workers has begun participating in Mopane, Limpopo with other pilot sites to follow.

Flourish took on franchisees to implement antenatal classes in the following communities:

Department of Health, Department of Monitoring & Evaluation, Department of Social Development. 2014. Final Evaluation Report: Short Diagnostic/Implementation Evaluation of Nutrition Interventions for Children from Conception to Age 5.

Department of Health, Department of Monitoring & Evaluation, Department of Social Development. 2014. Final Evaluation Report: Short Diagnostic/Implementation Evaluation of Nutrition Interventions for Children from Conception to Age 5.